Medical complications in pregnancy

1. Medical complications in pregnancy Dr Gemma Malin Consultant Obstetrician

2. Learning Objectives • Why is this important? • Pre-pregnancy counselling and first trimester care • Who needs early referral to secondary care? • Sources of information • What we offer at NUH

3. Medical condition

4. The women who died 2014-16 Impact on the mother

5. Causes of maternal death 2014-16

6. Short and long term morbidity Kapoor et al. Management of women with chronic renal disease in pregnancy TOG 2009,11: 185-191

7. Impact on the baby • Effects of the condition: • Miscarriage • Teratogenicity/ developmental problems • Preterm birth (spontaneous or iatrogenic) • Intrauterine growth restriction • Stillbirth • Effects of medication: • Miscarriage • Teratogenicity/ developmental problems • Intrauterine growth restriction • Neonatal effects (e.g. withdrawal, hypoglycaemia)

9. Physiologic changes of pregnancy • Cardiac • Increased cardiac output 40% • Reduced systemic vascular resistance • Haematological • Increase in plasma volume 50% • Hypercoagulable state (increased factor VIII, IX, X, fibrinogen, decreased anti-thrombin and protein S) • Renal • Increased renal blood flow and GFR • Reduced creatinine (80 is high for pregnancy) • Renal tract dilatation

10. GI • Increased stasis • Displacement of organs with growing uterus • Thyroid • Increased thyroid binding globulin • Reduction in free T3 and 4 • Glucose metabolism • Diabetogenic state • Progressive insulin resistance second and third trimesters • Respiratory • Increased oxygen requirement • Increased tidal volume (PEFR and FEV1 unchanged)

11. First contact with obstetrician under ‘consultant care’

12. Pre-pregnancy care • Stabilise condition • Change medication/ plan to change when pregnancy confirmed • Refer to secondary care for pre-pregnancy counselling • (if under a secondary care physician/ you are uncertain of the best advice) • Folic acid (5mg OD if BMI >30, diabetes, previous neural tube defect, women with epilepsy on medication) • Stop smoking • Reduce BMI <30. Refer women with BMI >50 for consideration of bariatric surgery • Consider VTE risk

13. Medical problems and pregnancy– sources of information for HCP • UK Tetralogy information service www.uktis.org • RCOG guidelines https://www.rcog.org.uk/en/guidelines-research-services/ • NUH guidelines https://www.nuh.nhs.uk/clinical-guidelines?smbfolder=181 • Obstetricians- how do I know who to contact? https://www.nuh.nhs.uk/maternal-medicine • If you need an urgent answer, ring labour suite

14. Sources of information for women • www.nhs.uk

15. Sources of information • www.medicinesinpregnancy.org

16. Sources of information • www.rcog.org.uk

17. Sources of information • www.nuh.nhs.uk/maternity

18. Thyroid disorders in pregnancy pathway • Refer women with current or previously treated hyperthyroidism to antenatal endocrine clinic (City/ QMC) • Community management of women with hypothyroidism: • Rationale- optimising thyroid function early aims to reduce the risk of pregnancy loss • Missed window of opportunity if seen for the first time at 12 weeks in consultant antenatal clinic

19. Available via NUH guideline link: • ‘Thyroid disease in pregnancy’

21. Take home messages • Medical conditions in pregnancy threaten lives & health of mother and baby • Prepare for pregnancy • FOLIC ACID • Pre-pregnancy counselling • If in doubt, don’t delay, ask for help • Refer complex women directly and early

22. Questions/ Discussion • Any medical problems you wish to discuss in more detail? • Local Maternity System working on improved digital flow of information between maternity providers and community health care professionals– what would be most useful?